++
Patients who present with a purulent discharge or who reside
in or have visited an area that is endemic for gonorrhea should
be offered treatment for both gonorrhea and chlamydia. Areas that are
hyperendemic for gonorrhea include many urban environments, the
southeastern United States, and developing countries. Current treatment
recommendations for gonorrhea include ceftriaxone, 125 mg intramuscularly,
or cefixime, 400 mg orally once. Cefixime, however, is not commercially
available in the United States and many authorities recommend another
third-generation cephalosporin, cefpodoxime, 400 mg once orally
instead. Because of the increased incidence of fluoroquinolone-resistant
gonorrhea (almost 40%) on the East and West coasts of the United
States in men who have sex with men, these drugs should not be used
in the treatment of that population. As of 2006, fluoroquinolones
continue to be recommended for treatment of gonorrhea in heterosexuals,
except in Hawaii and California. If fluoroquinolones are used in
populations where quinolone resistance is common, a “test
of cure” is recommended.
++
If the patient is a homosexual man or has a history of insertive
rectal intercourse, the clinician should consider the possibility
of enteric or anaerobic infection. Treatment for those infections
is similar to treatment for gonorrhea. All patients should be treated
presumptively for the other causative agents of urethritis (see
earlier discussion and Table 3–1) with azithromycin, 1
g as a single dose. An alternative regimen is to administer doxycycline,
100 mg twice daily for 7 days. Azithromycin is preferred for patients
with NGU because clinical trial data suggest that treatment success
rates for M genitalium are higher when
azithromycin rather than a tetracycline is used. Azithromycin, however,
does not treat incubating syphilis, so some public health authorities
recommend the use of tetracycline (doxycycline) in the treatment
of NGU in populations at high risk for syphilis.
++
Partners of patients with gonococcal or chlamydial infection
must be treated. Patient-delivered partner therapy has been shown
to be safe and highly effective in heterosexual men and women, and
this option, if available, should be used.
++
In addition, patients with gonococcal or chlamydial urethritis
should return at 3 months for repeat testing to rule out reinfection.
Some studies have shown rates of reinfection in adequately treated patients
to be as high as 20% at 3 months.
++
One of the biggest challenges to the clinician is presented by
the patient who reports urethral “tingling” without
discharge. Approximately one third of patients with clinically demonstrable
urethritis do not have discharge. If the results of diagnostic evaluation
are negative, these patients should be informed that no infection
is present and that the urethral discomfort will resolve spontaneously.
It is not uncommon for patients to experience urethral symptoms
after sexual experiences they later regret, suggesting a psychological
cause to their physical complaints. Testing and informing the patient
of the negative test results is often associated with resolution
of symptoms. Empiric treatment for urethral symptoms without objective
evidence of urethritis is not recommended
Burstein G, Zenilman JM. Non-gonococcal urethritis—-A
new paradigm.
Clin Infect Dis 1999;28(suppl
1):S66–S73.
[PubMed: 10028111]
(Comprehensive
review of the diagnosis and treatment of NGU, which served as the
background paper for the 1999 STD treatment guidelines. Includes
algorithms for diagnosis and management.)
Horner PJ. European guideline for the management of urethritis.
Int J STD AIDS 2001;12(suppl 3):63–67.
[PubMed: 11589800]
(Comprehensive European guidelines for the management
of urethritis.)
Kissinger P, Mohammed H, Richardson-Alston G, et al. Patient-delivered
partner treatment for male urethritis: A randomized controlled trial.
Clin Infect Dis 2005;41:623–629.
[PubMed: 16080084]
(Seminal article that describes the use of patient-delivered therapy
for treating partners of patients with gonococcal or chlamydial
infection, using reinfection as the outcome.)